Insulin and Hypoglycaemics and Endocrine

Question 1

as a rule, all insulin is given via what route?

Answer 1

s/c

except for sliding scales using short-acting insulin - Actrapid® or NovoRapid® - given by IV infusion

Question 2

what kind of insulin is Novomix 30®

Answer 2

a combination of short and medium acting insulin

Question 3

what is first line Tx for T1DM?

Answer 3

standard-release metformin

(gradually ↑ dose over several weeks to minimize the risk of adverse effects - GI)

if intolerable, consider modified-release metformin

monitor renal function before and during treatment with metformin

Question 4

CIs and cautions for metformin?

Answer 4

At risk of LACTIC ACIDOSIS:

• DKA
• eGFR <30 (standard) , <45 (modified)
• acute dehydration, fasting, infection, shock (renal function)
• HF, resp failure, recent MI, shock (tissue hypoxia)
• hepatic insufficiency, alcohol intoxication/addiction

ELECTIVE SURGERY:

• discontinue 48 hrs before if GA, spinal, or peridural anaesthesia
• Tx restarted >48 hrs following surgery/ resumption oral nutrition + if normal renal function

CAUTION:

• CKD
• elderly people (↑ risk of lactic acidosis)

Question 5

max daily dose of metformin?

Answer 5

2g

Question 6

if metformin not tolerated/CI?

Answer 6

sulfonylurea (GLICLAZIDE)

OR

• gliptin (dipeptidyl peptidase-4 inhibitor)
• pioglitazone
• Na+-glucose cotransporter 2 inhibitors (SGLT-2i)

Question 7

2nd line Tx for T2DM?

Answer 7

metformin/gliclazide + gliptin/pioglitazone

Question 8

3rd line Tx for T2DM?

Answer 8

met + glicla + gliptin/pioglitazone
consider insulin therapy

if 3rd line unaffective, consider adding in glucagon-like peptide-1 (GLP-1) mimetic

Question 9

if creatinine is >150, what drug to use as 2st line in T2DM?

Answer 9

gliclazide

beware metformin if renal impairment, or overweight

Question 10

sulfonylurea S/Es?

Answer 10

↑ weight
hypos
avoid in renal or liver impairment

(BNF says also common: abdo pain, D, N)

RARE:
SIADH
BM suppression (↓↓↓all bc)
liver damage (cholestatic)
peripheral neuropathy

Question 11

what time of day to take gliclazide?

Answer 11

mornings (to avoid overnight hypos)

Question 12

define a hypo?

Answer 12

< 4 mmol/litre

Question 13

how to Tx a hypo if patient is conscious?

Answer 13

oral glucose 10-20g

Question 14

how to Tx a hypo if patient is unconscious?

Answer 14

• 75ml glucose 20% IV (15 g) for an unconscious patient in hospital
• or 50ml (10g)
• or 100ml (20g bc 20%)

(also IM glucagon, but not ideal for patients who are anticoagulated + IV is more readily available)
- if glucagon ineffective after 10 mins give 20% glucose IV

Question 15

diagnosing a DKA? (3)

Answer 15

VBG pH < 7.3
glucose > 11
serum ketones >3, urine 2+

Question 16

Tx DKA?

Answer 16

• BP<90 500ml NaCl STAT
• BP>90 1 litre in 1 hr, then in 2/4/8
• K+ ↓ with Tx, therefore add 40mmol per litre if <5.5: measure at 60 minutes, 2 hours, and 2 hourly
• IV insulin mixed with NaCl to 1 unit/mL, given at fixed rate of 0.1 units/kg/hour (eg 50 units in 50ml)
• established S/C long-acting insulin (detemir or glargine) should be continued during Tx*

monitor:

• BM - aim ↓ 3mmol/L/h, when <14 start 10% glucose
• ketones - aim ↓ 0.5 mmol/L/h
• pH - aim >7.3

Continue insulin infusion until ketones< 0.3, pH >7.3, able to eat and drink, S/C fast-acting insulin and a meal, and stop infusion 1hr later.

Question 17

Tx HHS?

Answer 17

● hyperglycaemia (usually >35 mmol/L)
● hyperosmolar: osmolality >340 mmol/L (calculated by (x2 Na + x2 K) + urea + glucose)
● non-ketotic

Question 18

Tx HHS?

Answer 18

same as DKA except less fluids and only use insulin if glucose isn’t ↓ by 5mmol
risk of thrombosis so LMWH

Question 19

basic Tx of DM (1 + 2)? (4)

Answer 19

1) education and dietary/exercise advice
2) CV risk factor management: aspirin + simvastatin
3) annual review of complications: ACR (nephropathy), retinopathy, etc
4) blood glucose-lowering therapy

Question 20

is okay to use oral hypoglycaemic drugs in T1DM?

Answer 20

no! insulin, normally long acting

Question 21

blood glucose lowering therapy in T2DM?

Answer 21

HbA1c ≥48 (after trial of diet and exercise):

1) metformin (or if ↓/normal weight or creatinine >150 gliclazide)
2) then ↑ dose to max tolerated
3) then + gliclazide, or gliptin (DPP-4 inhibitor if already on gliclazide
4) then + insulin

Question 22

1st line in TDM overweight patients (as it causes appetite suppression)?

Answer 22

metformin

Question 23

is metformin okay to use in renal impairment?

Answer 23

avoid in those with a creatinine >150 μmol/L due to the risk of lactic acidosis

Question 24

1st line in T2DM if normal/underweight?

Answer 24

sulfonylureas

Question 25

first line IV treatment of hypoglycaemia?

Answer 25

glucose 20% (50-100ml)

• delivers between 10–20 g of glucose
• infusion rates <20 mins are optimal

(glucose 10% 100-200ml is suitable alternative)

Question 26

Tx: BM goals in adults and kids?

Answer 26

In adults: 4 and 9 mmol/litre for most of the time (4–7 mmol/litre before, < 9 after meals)

In children: 4 and 10 mmol/litre for most of the time (4–8 mmol/litre before, <10 mmol/litre after meals)

Question 27

what’s the most important consideration in creating an insulin regime?

Answer 27

strenuous efforts should be made to prevent it from falling below 4 mmol/litre

Question 28

if a patient is hyperglycaemic in the evening on their existing regimen of Humulin (biphasic isophane insulin) due to corticosteroids?

Answer 28

an increase in the usual insulin dose of 10% would be an appropriate way to manage a transient rise in blood glucose caused by corticosteroids
*****it is preferable to adjust the existing regimen, rather than add in an additional insulin prescription

Question 29

how much generally to increase units of insulin by to achieve BM target?

Answer 29

2-4 units sensible

Question 30

important prescribing info to give with metformin?

Answer 30

take with meals bc of bad GI S/E

check GFR

Question 31

effect of beta-blockers in DM?

Answer 31

reduce hypoglycaemic awareness

Question 32

Tx hypothyroidism?

Answer 32

• ↓ starting dose in elderly/IHD
• if CVD, severe ↓thyroidism or patients>50 years (starting dose 25mcg od)
• others started on 50-100mcg od
• following a change in dose TFTs checked after 8-12 weeks

Question 33

S/E levothyroxine?

Answer 33

hyperthyroidism: due to over treatment
reduced bone mineral density
worsening of angina
atrial fibrillation

Question 34

levothyroxine interactions?

Answer 34

iron, calcium carbonate

absorption of levothyroxine reduced, give at least 4 hours apart

Question 35

therapeutic goal of levothyroxine therapy?

Answer 35

• ‘normalisation’ of TSH
• normal TSH value 0.5-2.5 mU/l
• preferable to aim for a TSH in this range
• The TSH should be monitored carefully, aiming for a low-normal value

Question 36

women with established hypothyroidism who become pregnant?

Answer 36

should have their dose increased by at least 25-50 micrograms levothyroxine due to the increased demands of pregnancy

Question 37

what constitutes the basal and the bolus in basal-bolus insulin regimes?

Answer 37

BASAL:

• intermediate (isophane)
• long-acting (determir:Levemir) or (glargine:Lantus)

BOLUS:

• rapid (aspart: NovoRapid) or (lispro: Humalog)
• soluble short-acting insulins - Actrapid, Humulin S

Question 38

regarding time of surgery?

Answer 38

DM should be first on list!

Question 39

gliclazide in pregnancy?

Answer 39

hypo risk (never given!)

Question 40

metformin

Answer 40

always continued (in BF too!)

Question 41

1st line if ↑ weight?

Answer 41

metformin

Question 42

1st line if ↓weight?

Answer 42

gliclazide